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TBT: Primary, principal, and secondary diagnoses

ask ACDISQ: Sometimes I confuse the secondary diagnosis for the primary diagnosis. Do you have any tips for me to help me discern better?

A: This question touches on several concepts essentially at the core of CDI practices. I think you are confusing three definitions:

  1. Primary diagnosis
  2. Principal diagnosis
  3. Secondary diagnosis

Let’s take each of these individually.


Q&A: Be wary of over reliance on nurse practitioners for documentation

Deanne Wilk

Deanne Wilk

Q: We are getting pressure from our othopods to send all queries to their nurse practitioner (NP). Our facility bylaws allow NPs to function independently and they are allowed to answer queries without co-signature, so we routinely send queries to NPs who are caring for patients and we have great success with them.

The difference here is that the orthopods want us to send all queries to their NP, even if he/she is not caring for the patient. The ACDIS/AHIMA query guidelines tell us to query the provider that documented whatever needs clarification (though because we have a team approach with hospitalists, we often query the attending caring for the patient now, not necessarily the documenting provider). Our coding department has said they will not accept query responses from a non-treating provider. What do you think?

A: I have seen this happen at a number of facilities. They are using the NP/PA to do the “dirty work.”  There are varying opinions on this:

  1. NP will become very good at documentation and become your best friend
  2. Queries will get answered in a timely manner
  3. If they are going to respond to queries they must see the patient.  If not, they are a potential liability for the medical group and hospital.

I also wanted to respond to the group regarding who/where you can obtain documentation from:

  • Pathology = no
  • Echo = no
  • Radiologist = no (however,  CDI/coding can pull the specific fracture site and/or vessel sites directly from reports as long as the diagnosis is stated in the H & P/PN/Consult/ER, etc.
  • EKG = no
  • Cath report = yes

However, remember that in a query you can “refer” to that information.

 Editor’s note: Deanne Wilk, BSN, RN, CCS, CDI Manager at Penn State Health in Hershey answered this question. Make sure to work with your facility compliance and coding departments in incorporating any recommendations as advice provided is general in nature. Contact Wilk at

Q&A: Emergency room documentation and radiology reports

Take CDI into the emergency room

If the ER physician documents a diagnosis, but you see no evidence of treatment or monitoring, query for the significance of the diagnosis.

Q: Can you code strictly from emergency room (ER) documentation? Can you code from test results and imaging (radiologist reports)?

A: I am unsure what your mean by “strictly” from. Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ER physicians or other providers (NPs and PAs) can be used to base code assignment.

There are two elements of caution I would add. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ER physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.

As for the second piece of your question, diagnoses codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnoses codes, as such physicians do not provide direct patient care. We would need to query the attending provider to assign the appropriate diagnosis code.

Further guidance exists from the AHA Coding Clinic for ICD-10-CM/PCS regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident (CVA) from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit

Guest Post: Decipher encephalopathy coding and documentation challenges

Don't neglect nursing notes and nursing education when looking to strengthen your CDI program efforts.

To make the diagnosis audit proof, the physician needs to document the etiology of the encephalopathy.

“Encephalopathy is a great big monster,” says Timothy N. Brundage, MD, CCDS, medical director of Brundage Medical Group in Redington Beach, Florida. Coders and clinical documentation improvement (CDI) specialists want physicians to document encephalopathy, when appropriate, because it is an MCC.

By definition, encephalopathy is a global cerebral dysfunction in the absence of structural brain disease, Brundage says. “That definition is very nebulous.”

Unfortunately, providers often describe encephalopathy instead of diagnosing it, says Cheryl Ericson, MS, RN, CCDS, CDIP, [more]

Physician queries and education require ongoing efforts

German Shepherd

You can teach an old dog new tricks you might just have to try multiple times.

In the beginning, when placing queries for the type of heart failure or urosepsis, you may think that physicians will eventually learn the more specific documentation required and that your queries will no longer be necessary. I innocently thought that I would run reasons to query my physicians. Silly me!

Although not as frequently, I still had to ask those very same questions—hey doc, can you please specify the type of heart failure—years later. But I also found so many other opportunities for clarification as I grew in my understanding of the role and as clinical practice and coding rules changed.

I doubt I would have ever run out of questions, nor will you.

Many of the physicians I first worked with were very supportive and responded to education, queries, conversations etc., positively. Seeing my teaching reflected in their documentation was very encouraging. As with any group of students, however, there will always be the overachievers, the slow to grasp but committed learners, and those that just don’t understand why (nor do they care) clinical documentation matters to so much of the healthcare practice.

One physician (whom I very much learned to appreciate) sat down with me one day and said, “Laurie, did you know on average it takes 12 attempts to train a German shepherd to fetch but it takes 21 years to teach a doctor?”

So don’t worry about job security, because we are not training German shepherds to fetch, we’re helping physicians document the care they provide in a changing healthcare landscape. There will always be a reason to prove how valuable your assistance can be.

Provide CDI education ‘seven times, seven ways’

Don't let physician education become a tug of war at your facility.

Don’t let physician education become a tug of war at your facility.

When I started learning how to be an educator, I quickly learned the saying “seven times, seven ways.” The idea being we need to hear information repeatedly and receive it in a variety of ways before we are able to learn and incorporate that information in our daily practice.

Consider querying for clarification between renal insufficiency and renal failure, where the physician reads the query and asks you to just tell him what he should write. I would not start explaining the differences within the code set applied to these two terms or enter into a lengthy conversation about why the specificity is needed. Instead, point out the clinical indicators relevant to the patient as compared to the diagnostic criteria established for acute renal failure. Ask the physician to clarify if the kidneys are exhibiting failure or insufficiency based on the established criteria.

Stick to the facts. Keep it simple. Keep it relevant to the specific patient at the moment of conversation.

In this scenario, the physician needed a quick explanation. But let’s apply our “seven times, seven ways” theory by later following up on that interaction with an educational mailer or documentation tip via email to the physician. This second round of information could further highlight the needed differentiation and why this added level of specification is important to support issues such as extended length of stay, severity of illness, or resource consumption. Other ways to provide education include hanging posters in the physician lounges or documentation areas. I once even threatened to place fliers on a physician’s windshield!

The point is, that you may not always have the time (or the physician may not have the time) to engage in one-on-one education but you can use your physician queries as the first step in a more prolonged, detailed education campaign. We need to build upon each educational opportunity to reinforce the teaching. Repetition can be very valuable.

Summer meetings offer cool information for local CDI professionals

ACDIS currently has more than 40 local chapters in most states. The following groups are holding meetings this summer. Please also visit the local chapter page on the ACDIS website, and the local chapter-networking group category on the ACDIS Blog.

Hawaii: There will an Hawaii ACDIS Chapter meeting Wednesday, July 11. The agenda includes:

  • 11:45- Please come a little early because lunch pick up is different. Report to cafeteria and choose whatever you want for lunch. When checking out, say charge to Hawai‘i CDI association meeting.
  • 12:10- Round Table Discussion on 2012 ACDIS Conference
  • 12:20- “Getting Physician Buy-in”- Presented by Shun No Chan.
  • 12:35- “Tactics for Reducing the RAC Target on Your Organization”- Presented by Tammie Henderson
  • 12:50- RAC Discussion
  • Round Table: Discussion on when, where, to hold the next meeting, any other announcements, any other questions.

For information, contact Eleu Zane, RN, BS, BSN, C-CDI, Pali Momi Case Management, is gathering CDI professionals in Hawaii for networking. For information call 808/485-4281 or e-mail

Southern Nevada: Hold its meeting 5:30 p.m., Wednesday, July 18, at Kindred Hospital Flamingo in Las Vegas. Members who attended the ACDIS national conference are asked to share their experiences and takeaways with others.
North Carolina: The next NC ACDIS meeting takes place Friday, July 20, at CMC NorthEast in Concord. For information, call Leah Taylor at 704-878-7436 or Brenda Harris at 704-863-6378.
Tennessee: The next TN ACDIS meeting takes place 9 a.m. to 2:15 p.m., Friday, July 27, at the Faith and Healing Conference Center at Methodist University Hospital in Memphis. For information, contact Gina Jordan at or call 901-516-8632.
South Carolina: The next SC ACDIS meeting takes place Saturday, July 28, 9 a.m. to 2 p.m., at Waccamaw Community Hospital, Murrells Inlet, SC. If you did not RSVP and would like to attend, please do so by July 23rd.  Lunch will be provided. Please RSVP to
West Virginia: The next WV ACDIS meeting will be held 1-3 p.m. Wednesday, August 15 at Thomas Memorial Hospital in South Charleston. For information, contact Sheila Harrison at 304-389-0689 or email
Kentucky/Southern IN: The KY and IN ACDIS chapters will host a combined regional chapter meeting 9 a.m. to 4 p.m., Thursday, August 23, at Columbus (IN) Regional Hospital. For information, contact Susan Bradford at 317-776-7285 or email

Alabama: The next meeting for Alabama ACDIS will be 10 a.m. to 2 p.m., Saturday, August 25, at Huntsville Hospital Corporate University.  For information, contact Margaret Stephens, or 256-658-6113. For facility information visit

New York: The New York City/Five Boroughs networking group holds it inaugural meeting 4-6 p.m., September 20, at the Wyckoff Heights Medical Center in Brooklyn. RSVP by August 2, to Wanda Mejias-Gonzalez by calling 718-302-8542 or email

Oregon: The NW (Oregon) ACDIS Chapter holds its fall conference, 8:15 a.m. to 3:30 p.m., Friday, October 19, at Legacy Meridian Park Medical Center in Tualatin, Ore. Agenda includes:

  • Robert Gold, MD CEO, DCBA, Inc., will discuss “RAC Proofing Documentation and how to help physicians get it.”
  • James Suiter, NP, CCDS, will discuss “Dementia, Encephalopathy, and Delirium.”
  • Richard D. Pinson, MD, FACP, CCS, Co-Founder and Principal of HCQ Consulting, will discuss “VBP Impact on CDI/Using Outcomes Data Effectively.”
  • National benchmarking results discussion from summer survey
  • Business Meeting: Officers Report, state of the organization, election of officers for 2012, raffle drawing

To register, fill out the form and fax to Juanita Carriveau  at 541-222-2427. For additional information, email

Coding for inpatient postoperative complications requires explicit documentation

Capture appropriate documentation for coding postoperative complications.

Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.

A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.

Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”

For a condition to be considered a postoperative complication all of the following must be true:

  • It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
  • There must be a cause and effect relationship between the care provided and the condition
  • Physician documentation must indicate that the condition is a complication

According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”

Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”

For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.

“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.

Editor’s Note: This article first published on

To register for the July 12 program visit

Take 10 steps to refresh your documentation review process

Ensure your CDI programs examines patient records "door-to-door."

I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.

I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.

Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.

Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?

Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?

Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.

Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.

Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.


Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at